The Office of the Medicaid Inspector General (OMIG) was recently given a set-back in its on-going audits of nursing home case mix submissions. These audits focus on “Patient Review Instruments” (PRIs) which form the basis of Medicaid reimbursement of direct care costs. The LTC industry has been battling the standards used by OMIG as they are very distinct from prior audits conducted by DOH and IPRO. In a recent decision, an Adminstrative Law Judge (ALJ) reversed OMIG on specific standards which were held to be arbitrary and capricious since they did not properly assess the level of documentation needed to support PRI classifications of care needs. (See Meadowbrook Healthcare v. OMIG, Decision after Hearing, June 29, 2015.)

The ALJ noted that OMIG was legally authorized to conduct PRI reviews and had done so in conformity with governing DOH regulations. Significantly, however, the OMIG’s standard, not specifically found in regulation, was held deficient in that it was unclear as to what specific “time” was required to be documented. The OMIG standards were deemed to be new interpretations of PRI regulations and unsupported by prior DOH clarifications or audits, first provided to the LTC industry when PRI audit standards were rolled out over 15 years ago. Furthermore, the ALJ held that OMIG improperly discounted the veracity of the nursing home’s clinical documentation without factual justification.

Bond’s Rate Reimbursement team represented the facility in this matter.